Which medication should be increased in a patient with increased delusions taking Abilify (Aripiprazole), Risperidone, Sertraline, and Ativan (Lorazepam)?

Increase Aripiprazole (Abilify) to 5-10 mg Daily

For a patient with increased delusions on this medication regimen, increase the aripiprazole (Abilify) dose from 2.5 mg to 5-10 mg daily, as this is the primary antipsychotic targeting the delusions and is currently at a subtherapeutic dose. 1, 2, 3

Rationale for Increasing Aripiprazole

• Aripiprazole is specifically effective for delusional symptoms and has demonstrated marked improvement in patients with delusional disorders who failed other antipsychotics 4, 3

• The current dose of 2.5 mg is below the therapeutic range for treating psychotic symptoms; the effective dose range for delusions is typically 5-30 mg daily, with an average effective dose around 11 mg daily 3

• Aripiprazole offers superior tolerability compared to increasing risperidone or other antipsychotics, with fewer extrapyramidal side effects, less metabolic impact, and better long-term adherence 3

Why Not Increase the Other Medications

Do Not Increase Risperidone (Injectable)

• The patient is already receiving risperidone 2 mL every 2 weeks (likely Risperdal Consta 25-50 mg), which provides adequate baseline antipsychotic coverage 5
• Increasing risperidone would add metabolic risks (diabetes, dyslipidemia, weight gain) and extrapyramidal symptoms without addressing the specific issue of breakthrough delusions 2
• Having two antipsychotics at therapeutic doses is preferable to monotherapy at higher doses when one is already established 2

Do Not Increase Sertraline

• Sertraline at 200 mg daily is already at maximum dose and antidepressants do not directly treat delusions 6
• Sertraline is appropriate for comorbid depression/anxiety but will not address the psychotic symptoms 6

Do Not Increase Ativan (Lorazepam)

• Benzodiazepines are contraindicated as treatment for delusions and can actually worsen delirium and psychotic symptoms 7
• Lorazepam 1 mg BID is already a concerning dose for chronic use; benzodiazepines should be reserved only for acute agitation threatening harm, not for ongoing delusional symptoms 7
• Consider tapering the Ativan once aripiprazole is optimized, as chronic benzodiazepine use increases fall risk, cognitive impairment, and paradoxical agitation 7, 8

Specific Dosing Strategy

• Start by increasing aripiprazole to 5 mg daily for one week, then assess response 3
• If delusions persist after one week, increase to 7.5-10 mg daily 2, 3
• The average time to achieve clinical response with aripiprazole is 5-7 weeks, so allow adequate trial duration 3
• Maximum dose can go up to 15-30 mg daily if needed, though most patients respond to 10-15 mg 2, 3

Monitoring and Safety

• Monitor for akathisia and restlessness, the most common side effects of aripiprazole, though these are less frequent than with risperidone 3
• Watch for insomnia (can dose in morning if this occurs) and mild extrapyramidal symptoms 3
• Aripiprazole has minimal metabolic effects compared to olanzapine or risperidone, making it safer for long-term use 2, 3
• Avoid combining with strong CYP3A4 or CYP2D6 inhibitors without dose adjustment 5

Common Pitfall to Avoid

Do not reflexively increase the long-acting injectable risperidone when a patient has breakthrough symptoms on combination therapy. The aripiprazole is severely underdosed at 2.5 mg and represents the more logical target for optimization, especially given its specific efficacy for delusional symptoms and superior side effect profile 4, 3.